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Counseling Intake FormEach person attending therapy should complete a separate form.Full Name:Nickname: Gender:MaleFemale D.O.B.: Age:Mailing Address:City: State: Zip:Home Phone: Cell: Work:May we leave a messageon your home phone? Yes NoBest Phone for us to Contact you:CellMay we leave a message and/or texton your cell phone? Yes NoHomeMay we leave a messageon your work phone? Yes NoWorkE-mail: Is it okay to contact you via email?YesNoReferral Source/How did you hear about this counseling practice?May we contact them to thank them for the referral when applicable?YesNoIf yes, please provide their contact information:Emergency Contact:Relationship to Client: PhoneMy Current Overview:The major concern(s) that led me to seek help:My problem / symptom(s) began: (date). My symptom(s) increased: (date).My three biggest worries/concerns in life now are: 1.2. 3.Any medical problems / Surgeries:Current Medications and dosage (include psychiatric, sleep, over-the-counter, vitamins and supplements):Name of Primary Physician:Date of last lab work: Results: Health:ExcellentGoodFairPoorName of Psychiatrist (if applicable):HeartLink Intake FormPage 1
Current Symptoms (check all that apply):Increased CryingSad MoodLack of MotivationSleep Pattern (More) or (Less)Appetite Changes or Weight Changes or Lack of InterestDecreased Self EsteemHopeless / Helpless FeelingEnergy Level or Chest DiscomfortAbdominal (Stomach) DistressFeeling DizzyFear of Going CrazyStartled ResponseChills or Hot FlashesOutburst of AngerAnxiety in GeneralPanic AttacksRestlessness, Keyed Up,Fatigued, DecreasedConcentration, Irritability,Muscle Tension, DecreasedSleepHypervigilance - excessiveattention & focus on internaland external stimuliObsessions / CompulsionsEx: constant checking,washing, or counting typebehaviors; unrelenting worriesAvoidance of stimuliassociated with traumaAgoraphobia - anxiety ofplaces or inescapablesituationsSocial Anxiety - marked &persistent fear of social orperformance situations whereembarrassment may occurPhobia (specify):Post-Traumatic StressIntense FearFlashbacksRapid Heart BeatIncreased SweatingTremblingShortness of elusions/ParanoiaHallucinations (hearing voicesmusic that no one else hears,seeing things no one elsesees)High with Racing Thoughts,Increased Speech, DecreasedSleep, and Increased ActivityImpulsiveIsolating self from all contactwith othersMemory impaired with troubleorganizing & sequencingAmnesia / Lose TimeSomatization - undue healthworries with adequate medicalexplanationAgitated - Irritable (easilyannoyed provoked to anger)Chronic Pain (specify):Alcohol Abuse: # of drinks inthe last week:Substance Abuse:Drugs you’ve used:Behavioral Problems:Developmental Problems:Self-Mutilation:Legal Issue(s):Sexual Issue(s):Eating Issue(s):Grief / Loss:Other:SUICIDE IS A DEFINITEPOSSIBILITY NOWYesNoMy History:Have you had similar problems/symptoms in the past?Did they recently increase?YesYesNo. If yes, when:No. What caused the increase?Name 3 past stressful events in your life that precipitated the original symptom(s):My Birth and Early Development was:NormalAbnormal. If abnormal, explain:My childhood was overall:I have a history of:Job ProblemsAbusePainfulSchool ProblemsLegal ProblemsHeartLink Intake FormUneventfulGoodAbandonmentRelationship ProblemsDisabilityOther:Page 2
My Family of Origin to Present:Father - What was he like?Mother - What was she like?Brothers / Sisters - how many of each?Where did you fit in the birth order?What type of relationship did you have with your siblings?Marriages - How many? What types of stress in marriage?Children - How many? Ages and sex of each?School History:High SchoolGEDVocational or Trade SchoolSome CollegeCollege Graduate - Where / Degree(s):Job History: Current Job:Religious History (past to present):Counseling / Psychiatric History:Prior Outpatient Counseling:YesPrior Psychiatric medications:No. Therapist: Date(s):YesNo. Specify meds:Prescribing Doctor: Date(s):Prior Psychiatric Hospitalization?Substance Abuse History?Any treatment?YesYesYesNo. Where: Date(s):No. When began? Substances:No. Facility: Date(s):Past & Current History Summary:I grew up in (state). I grew up in thewerewere not in the home. My childhood wascountrygooda small towndifficult. My teen years werea large city. Both parentsvery difficult in the sense ofgooddifficultvery difficult in thesense of . In high school my life revolved aroundwork,church,social,academics,has beengooddifficultcurrentlysinglemarried for years. I presently liveother: . After high school, lifevery difficult in the sense of . I amaloneother (specify): . My current support system iscenters arounddifficultfamilysports,workfriendswith my spousegoodfairwith my parentspoor. Life nowother: . Recently life has beengoodvery difficult in the sense of .Genetic factorsdo notdo seem to contribute in that relative(s) of mine (specify):had . My spiritual lifehashas not beena factor in the sense of .HeartLink Intake FormPage 3
Self Rating Report of SymptomsRate each symptom in the list below using the following 0 to 10 scale.0 - - - - - - - - - - - - 1 - - - - - - - - - - - - - - - - - - - - - - 5 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -10Almost NeverPresent a smallamount of the timePresent most of the time,to a significant degreeAs SevereAs PossibleSymptomRatingAdditional InfoDepressionSad, down feelingAnxietyNervous, tense, apprehensionInsomniaCircle all that Apply: Difficulty falling asleep,difficulty staying asleep, early morning awakeningsLow EnergyTired, fatiguedAngerIrritable, angry, frustratedLow MotivationLow initiative, low interestsManicOverly high, overly energetic, poor judgement, rapidthinkingInattentionTrouble paying attention, distractible, forgetfulBehavior ProblemsSpecify:HyperactivityHyperactive, fidgetOCDObsessions / Compulsions / Repetitive, irrational worryor actionsTrouble FunctioningCircle all that apply: at work, socially, other:DysthymiaSad mood most days for last 2 years -StressedList Stressors (including recent changes):YesNoWorryWorry most days for the last 6 months -YesNoPainSpecify:Mood SwingsDrastic changes in moodDecreased CognitionDifficulty thinking, decreased ability to retain or learninformationAuditory HallucinationsHearing things that are not thereVisual HallucinationsSeeing things that are not thereParanoiaIncreased suspicion or exaggerated distrust of othersNightmaresI certify the information provided in this Counseling Intake Form is correct to the best of my knowledge.Signature Date:HeartLink Intake FormPage 4
Client Agreement / Informed ConsentWelcome to HeartLink Christian Counseling!Whether you need brief supportive therapy or have wounds from the past that are impactingyou today, it is our goal to be a safe place for you. We work with our clients in a collaborativeway to achieve their goals. Hope often emerges when we invite God and safe people into themess. We look forward to joining you on the journey in a way that creates space for hope,healing and connection.Overview of ServicesWe offer counseling services for individual adults, couples and families. Counseling andpsychotherapy both refer to a supportive relationship with a professional practitioner who hasundergone extensive training and personal exploration to understand the dynamics of humanexperience and psychological development. At HeartLink, not only do we have extensivepsychological training, we are also Christ followers. We work collaboratively with you in relianceon God for a treatment plan that considers your spiritual, psychological, biological and socialdimensions.Experience and EducationStacey W. Farmer is a Licensed Professional Counselor with a master’s degree in counseling fromDallas Theological Seminary. She worked with Dr. Frank Minirth for over 16 years at the MinirthClinic as a counselor. She deeply enjoys and has extensive experience helping clients withdepression, anxiety, trauma, abuse, obsessions, loss, anger, sense of self, relationships andspiritual issues. She is also passionate about coming alongside people who have wounds from thepast that are affecting present day living. Because of this she pursued training in two other areas.First, she received a Doctor of Ministry in Formational Counseling in 2009. Next, she becamecertified in EMDR therapy in 2017.TherapyEffective therapy requires a partnership of mutual respect between the therapist and client. Wewill work together to determine what makes the most sense at this juncture in your life.Progress depends on a number of factors including the therapeutic alliance and the client’savailability to work toward goals in between sessions. Benefits of therapy include finding a freshperspective or resolution to a difficult problem; developing skills for improving relationships;learning new ways to navigate stress, anxiety, anger or depression; working through trauma orloss; having a safe context to process and release wounds; growing in connection with self, Godand others; and living in increasing health, hope and freedom.Certain discomforts and tensions associated with the counseling process should be understoodbefore work begins. These include but are not limited to the following: 1) Recalling unpleasantevents can surface feelings of fear, anger, sadness and other strong emotions that may beuncomfortable but are a normal part of the healing process. 2) Significant relationships mayexperience varying degrees of tension. 3) Sometimes problems temporarily worsen at thebeginning of treatment. Most of these are to be expected when someone is making significantchanges. It is impossible to guarantee specific therapy results; however, it is our goal to workwith you to achieve the best possible results for you.Client Agreement / Informed ConsentPage 1
ConfidentialityPsychotherapy, counseling, assessment and associated services that are related to the diagnosis,evaluation and treatment provided by licensed professionals are confidential and protectedunder Texas state law. All communications and records with your counselor are held in strictconfidence, with the following exceptions: 1) The client signs a written release indicating consentto release records or share information regarding treatment; 2) the client is at risk of imminentserious harm to self or someone else; 3) mandated reporting of any known abuse, neglect orexploitation of a minor, elderly person or disabled person; 4) a court order is received directingthe disclosure of information; and 5) as outlined in the HIPAA Notice of Privacy Practice.Electronic CommunicationConfidentiality cannot be guaranteed with electronic communications, including telephone calls,voice mails, texts, emails and faxes. These electronic modes may be used for scheduling andother communications. If you would prefer not to be contacted by a certain method ofcommunication, please note this on the Counseling Intake Form and we will honor your request.Should you want to make changes to your preferred method of communication you can let yourcounselor know at any time.Therapeutic RelationshipThe client-therapist relationship is a professional collaboration. Over the course of treatment,therapy can be psychologically intense and emotional. For an effective therapeutic environment,it is a necessary requirement that we maintain a professional relationship and not a social one.Counseling Sessions/FeesGenerally, counseling sessions are 45-50 minutes on a weekly basis for a fee of 125 per session.Session frequency, length and fee may vary depending on the client’s specific needs. A client canrequest a 90-minute session ( 225 per session) when scheduling an appointment. Additionally,EMDR therapy sometimes requires an extended session; if so, this will be discussed in advancewith the client.Payment is due at the time of service. We provide a billing receipt so you can file your claim forinsurance reimbursement when applicable. We accept cash, check, HSA, Visa, MasterCard,American Express, and Discover. A service charge of 35 will be charged for each check returnedto HeartLink Christian Counseling. After receiving a returned check, we will only accept cash orcredit card payments.Scheduling and CancellationIf you are unable to keep a scheduled appointment or need to change an appointment, pleasenotify our office as soon as possible. Sessions must be cancelled with at least a 24-hour notice toavoid the full session fee.Litigation FeesIf your therapist’s involvement is required for litigation, the fee is 300 an hour. This includestime spent in photocopying, preparation, travel time, deposition and courtroom appearances. A 900 retainer fee for all court and legal-related services is due at least 48 business hours beforethe scheduled appearance.Client Agreement / Informed ConsentPage 2
ReferralsA client has the right to withdraw from our agreed-upon treatment process at any time andrequest a referral for any reason. It is recommended that you schedule a termination session forreaching closure. Counselors reserve the right to withdraw from
She worked with Dr. Frank Minirth for over 16 years at the Minirth Clinic as a counselor. She deeply enjoys and has extensive experience helping clients with depression, anxiety, trauma, abuse, obsessions, loss, anger, sense of self, relationships and spiritual issues. She is also passionate about coming alongside people who have wounds from the past that are affecting present day living .
